Lovelace Health System, Inc. :LHS Basic Option

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1 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions Answers Why this Matters: $500 individual/$1,500 family for Participating per calendar year. $1,000 individual/$3,000 family for Non-Participating per calendar year. What is the overall deductible? Are there other deductibles for specific services? Is there an out-of-pocket limit on my expenses? What is not included in the out-of-pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? No. Yes. $4,500 individual/$13,500 family for Participating per calendar year. $9,000 individual/$27,000 family for Non-Participating per calendar year. Vision and Rx charges, co-payments, annual deductible amounts, balance-billed charges, premiums, and non-covered benefit charges. No. Yes. For a list of preferred providers, see or call No. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. You don t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don t count toward the out of pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Yes. Some of the services this plan doesn t cover are listed on page 3 and/or 4. See your policy or plan document for additional information about excluded services. M589R138 Page 1 of 8

2 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use participating providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider's office or clinic Services You May Need Your Cost If You Use an In-Network Participating Your Cost If You Use an Out-of-Network Non-Participating 30% after deductible Limitations & Exceptions Primary care visit to treat an injury or illness $30/visit None Specialist visit $40/visit 30% after deductible None Other practitioner office visit $20/visit Acupuncture $20/visit Chiropractic 30% after deductible Coverage is limited to 20 visits/calendar year for each benefit. Preventive care/screening/immunization No Charge 30% after deductible None If you have a test Diagnostic test (x-ray, blood work) No Charge; included with 30% after deductible None co-payment for applicable visit or facility charge Imaging (CT/PET scans, MRIs) $150/test 30% after deductible None Page 2 of 8

3 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www. lovelacehealthplan.co m. If you have outpatient surgery If you need immediate medical attention If you have a hospital stay Services You May Need Generic drugs Preferred brand drugs Non-Preferred brand drugs Specialty drugs Your Cost If You Use an In-Network Participating $10 Lovelace Retail (30 days) $15 Other Retail (30 days) $20 Mail Order (90 days); No Charge for generic contraceptives or brand-name contraceptives with no generic equivalent. $30 Lovelace Retail (30 days) $35 Other Retail (30 days) $60 Mail Order (90 days); No Charge for generic contraceptives or brand-name contraceptives with no generic equivalent. $50 Lovelace Retail (30 days) $55 Other Retail (30 days) $100 Mail Order (90 days) 20% of charges Retail (30 days); a minimum of $50, and a maximum of $250 per prescription per Your Cost If You Use an Out-of-Network Non-Participating Not Covered Not Covered Not Covered Not Covered Limitations & Exceptions None None None Coverage is limited to drugs obtained at the Lovelace Specialty Pharmacy. Not available through Mail Order. month. Facility fee (e.g., ambulatory surgery center) 20% after deductible 30% after deductible None Physician/surgeon fees 20% after deductible 30% after deductible None Emergency room services $150/visit $150/visit None Emergency medical transportation $50/trip Ground $50/trip Ground None $100/trip Air $100/trip Air Urgent care $75/visit $75/visit None Facility fee (e.g., hospital room) 20% after deductible 30% after deductible None Physician/surgeon fees 20% after deductible 30% after deductible None Page 3 of 8

4 Common Medical Event If you have mental health, behavioral health, or substance abuse needs Services You May Need Your Cost If You Use an In-Network Participating Your Cost If You Use Limitations & Exceptions an Out-of-Network Non-Participating 30% after deductible None Mental/Behavioral health outpatient $40/visit for Outpatient Services services $30/session for Group Therapy Mental/Behavioral health inpatient services 20% after deductible 30% after deductible None Substance use disorder outpatient services $40/visit for Outpatient Services 30% after deductible None $30/session for Group Therapy Substance use disorder inpatient services 20% after deductible 30% after deductible None If you are pregnant Prenatal and postnatal care 20% after deductible 30% after deductible None Delivery and all inpatient services 20% after deductible 30% after deductible None If you need help recovering or have other special health needs Home health care 20% after deductible 30% after deductible Coverage is limited to 100 visits/calendar year. Rehabilitation services 20% after deductible 30% after deductible None Habilitation services 20% after deductible 30% after deductible None Skilled nursing care 20% after deductible 30% after deductible Coverage is limited to 60 days/calendar year combined. Durable medical equipment 20% after deductible 50% after deductible None Hospice service Inpatient:20% after deductible Outpatient: No Charge 30% after deductible None Page 4 of 8

5 If your child needs dental or eye care Eye exam $20/exam Charges over $50 Coverage is limited to one exam, covered in full, per calendar year. Glasses Lenses- Covered in full Frames-Covered up to $120 Dental check-up Excluded Services & Other Covered Services: Contact: Delta Dental of Tennessee at Lenses- Single:covered up to $50 Bifocal: covered up to $75 Trifocal: covered up to $100 Progressive: covered up to $75 Frames-Covered up to $70 Contact: Delta Dental of Tennessee at Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Cosmetic surgery Dental care (Adult or Child) Hearing Aids (Adult) Long-term care Non-emergency care when traveling outside the U.S. Private-duty nursing Routine eye care (Adult) Routine Foot Care Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Acupuncture Bariatric Surgery Chiropractic Care Infertility Treatment Weight Loss Programs Coverage is limited to one pair of lenses per calendar year. Coverage is limited to one frame every two (2) calendar years. No coverage for dental. Page 5 of 8

6 Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: Lovelace Health Plan Customer Care Center at In addition to speaking to one of our Customer Care Representatives by phone, you can also express your Concerns by walk-in interview or arranged appointment at the address below. Lovelace Health Plan 4101 Indian School Rd, NE Albuquerque, NM You may also submit your Concerns in writing to the above noted address or by fax to (505) Department of Labor s Employee Benefits Security Administration at EBSA (3272) or You may also contact your state insurance department by mail to the Superintendent of Insurance: ATTN: Managed Health Care Bureau - External Review Request, New Mexico Public Regulation Commission, P.O. Box 1269, 1120 Paseo de Peralta, Santa Fe, New Mexico ; or to mhcb.grievance@state.nm.us, subject: External Review Request; You may fax to the Superintendent of Insurance, ATTN: Managed Health Care Bureau - External Review Request at (505) ; or Completed on-line with a NM PRC, Division of Insurance Complaint Form available at Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' To see examples of how this plan might cover costs for a sample medical situation, see the next page Page 6 of 8

7 About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Vaccines, other preventive Total Total Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $5,630 Patient pays $1,910 Sample care costs: Hospital charges (mother) Routine obstetric care Hospital charges (baby) Anesthesia Laboratory tests Prescriptions Radiology Patient pays: Deductibles Copays Coinsurance Limits or exclusions $2,700 $2,100 $900 $900 $500 $200 $200 $40 $7,540 $500 $0 $1,410 $0 $1,910 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $4,680 Patient pays $720 Sample care costs: Prescriptions Medical Equipment and Supplies Office Visits and Procedures Education Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles Copays Coinsurance Limits or exclusions $2,900 $1,300 $700 $300 $500 $60 $160 $0 Total $720 Page 7 of 8

8 Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? û No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? ûno. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? üyes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? üyes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-of-pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Page 8 of 8